23D-132 (8) 73 HINCKLEY ST BP-2001-0147
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D- 132 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:demolition BUILDING PERMIT
Permit# BP-2001-0147
Project# JS-2001-0228
Est.Cost:$200.00
Fee: $10.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 24480.72 Owner: ROOSA DOUGLAS F&DIANE E FABI
Zoning:URB Applicant: ROOSA DOUGLAS F & DIANE E FABI
AT: 73 HINCKLEY ST
Applicant Address: Phone: Insurance:
73 HINCKLEY ST (413) 586-9384 ()
FLORENCEMA01062 ISSUED ON:8/9/00 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMOLISH ATT/GARAGE NO ELECTRICAL
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Final: Final:
Rough Frame:
Gas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/9/00 0:00:00 1168 $10.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2001-0147
APPLICANT/CONTACT PERSON ROOSA DOUGLAS F&DIANE E FABI
ADDRESS/PHONE 73 HINCKLEY ST (413)586-9384 O
PROPERTY LOCATION 73 HINCKLEY ST
MAP 23D PARCEL 132 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid �i
Building Permit Filled out 4 i t0
Fee Paid
Typeof Construction: DEMOLISH ATT/GARAGE NO ELECTRICAL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE�LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
,V Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Signature of Buildi fficial (/ Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
j(,t
F •
Department use only
u1 ity of Northampton Status of Permit:
:uildiia Department Curb Cut/Driveway Permit
DEFT oE$UItDING�"' -"--212 ain Street Sewer/Septic Availability
NORIH4MPTQN MA 01 60hs R om 100 Water/Well Availability
or ton, MA 01060 Two Sets of Structural Plans_
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
I Vs: i Map l p�
3P Lot Unit
tox-R--v%� Zone ., Overlay District
��/�-�`
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
\ _ ���,SI . floc2 •ce o\o .
:: rmn
a(P Current Mailing Address:
Telephone
natu
2.2 Authorized nt:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 7r�J�6 (4,%%. 1 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: -FpO/J/ Date Issued:
oignature:
Building Commissioner/Inspector of Buildings Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
� q Building Department
j,
Lot Size `T
Frontage ( `�v
Setbacks Front (
Side L: R: 3 " L: R:
Rear I coo'
Building Height I a a
Bldg. Square Footage 33 7
Open Space Footage .7 03 3
(Lot area minus bldg&paved
parking)
#of Parking Spaces tL
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
( D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
0
New House 0 Addition ❑ Replacement Windows Alteration(s) 0 Roofing 0
Or Doors 0
Accessory Bldg. 0 Demolitio' New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: IiA3.( V&rsxv ry j Y4t\ plex-k1l(-4.k
Alteration of existing bedroom Yes le-- `
No Adding new bedroom Yes 4- No
Attached Narrative❑ Renovating unfinished basement Yes _ No
Plans Attached Roll n - Sheet n
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
•. Type of construction
i. Is construction within 100 ft. of wetlands? _ Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Mr
P 'nt Name j �Y
7
Signature o Owner/ t
Dat � t. 1/
SECTION 8 - CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: °, Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 0 No 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"ho eowner ertifies and ume responsibility for compliance with the State Building Code,City of
Northampton Ordin es, State a d Local oning ws and State of Massachusetts General Laws Annotated.
�Homeowner Signature / \,
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F� `� �� .c (rii� ofNorthampton I —
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DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 r'
WORKER'S COMTENSATION INSURA_NCL AFFIDAVIT
L %'''-...__'_'D.__C) ____Rc .
(li ccuscdpcTmi ttcc)
with a principal place o business/residence at:
L--/
(..! 423
���r� 4'W"` dkSc . 1 14QCtsna., 01" ne ) ---� I
(sar,.,t/ci ty/statelzi p)
do hereby certify, under the pains and penalties of perjury, than.
( ) I am an employer providing the following worker's compensation coverage for my
employees woring on this job:
(Insuranc Company) (Policy Number) (T:-pirat on Date)
• ( ) I am a sole proprietor, general contractor or homeowner(cycle one) and have hired
the conn-actors listed below who have the following worker's compensation policies: .
(Name of Contractor) (Insurance ColnpanyfPoiic— Ntunbcr) (Expiration Date)
,t,
(Name of Contractor) (Insurance ComoanyiPo!icv Nunlc-er) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Numb,u) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(mach h addfaocal,thee if noocs.ry to mcu&inforasaj oa pertaining to all oocc actors)
( ) I am a sole proprietor and have no one working for me.
. ,, , m.aa home owner performing all the work myself.
NOTE:pIca be aw-ari thtt‘nbilc be,nceseocrs o.ho ccoplay pasoas to de c-'r,-1n+0,> cry.scion a repair work.cm a dssclling of
not mock than three tzar in which the homeowner rides or oo the grnurvii appurt.caam th -eo Lr wt g".Jiy oecsid td to Sc
employes undc the t ackces Sim Act(GL152,so1(5)),application by a homeowner fare(incase or I,�mit rr..y cvtdcocc(Sc
legal ctaatc of an caployer under rho Worker's CocapooyAtipa Ad..
I undaztand that a copy of Chit mtcmmt may be forwarded to the Dcpertmcot of 10.4+,erial Anadmtf Otfioo of leder-ooa for the
coverage vtiiGertioo and that failtac to trout coverage under soctioa 25A of MOL 152 can lad to the i iporilioa of criminal pcatllicr
cooatrmg of a tint of up to 31.300.00 and&rx imprisonment of up to roc yesr and civil p-a•ltia in thx form of a Stop Work order and a
1no 0 .00 a thy tttiQT(mG
For dcp.rtm-...-1 u,c Drily
Permit Number
�' r
• t` T Map:7_ Lot
Signature of Li crmiucc 13i'